WENDY LOPEZ
Dependent on policy B03M000363
Claims
2
Attributed to this person
Charged
756.00
Total submitted
Denied
268.00
2 denied claims
Patient responsibility
317.20
Reported on the 835
Patient responsibility is the amount reported on the 835 as assigned to the patient — deductible, coinsurance or copay. It is not proof that the provider billed the member, that the member owes it, or that it was collected, and it is kept separate from denied amounts throughout.
Who this is
| Field | Value |
|---|---|
| Name | WENDY LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B03M000363 |
| Date of birth | 7 Jul 2004 |
| Plan | SILVER HMO |
| Covered from | 26 Jan 2024 |
| Covered to | 15 Jul 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 317.20 |
| Total | 317.20 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001472 | 10 Mar 2024 | 488.00 | MERIDIAN HEALTH PLAN | CARC 96 · NON_COVERED | 0.00 |
| CLM0001473 | 14 Jan 2024 | 268.00 | MERIDIAN HEALTH PLAN | CARC 27 · ELIGIBILITY | 268.00 |